Chapter 1: Aesthetics and Aging and A New Paradigm:
Introduction 
Many book chapters and scientific papers have been written about the aesthetic evaluation of the aging face with a plethora of lines and measurements, philosophies, and perspectives to instruct the reader in that analysis. This chapter will not review the past literature but instead attempt to propose a new way of looking at the maturing face - one that is particularly relevant to the surgical therapies outlined in this book. In a certain respect, the aesthetic surgeon has to unlearn much of his or her education up to this point. Past theories on the aging face have focused solely on facial descent as the primary mechanism for facial aging. Accordingly, a facelift, browlift, and blepharoplasty were used as the principal weapons to combat and to reverse the aging process. All of these procedures are contingent upon excision and lifting of redundant, prolapsed, or descended tissue.
A new paradigm has emerged to supplant this established dogma - the face does not descend so much as contract by virtue of volume loss. Two pioneers have led the charge for fat enhancement: Sydney R. Coleman of New York and Roger Amar of France. Coleman has been an eloquent and outspoken proponent of this new thinking. He reasons that the face undergoes soft-tissue and fat loss. Therefore, volume expansion with facial fat grafting is the method by which the aging process can be reversed. Roger Amar, a studious and meticulous individual, has advocated a strict anatomic program for facial rejuvenation in which fat is infiltrated systematically into the face using the facial muscles as the recipient bed, known as FAMI, or Fat Autograft Muscle Injection.
A simple simile can be instructive and illuminating when thinking about the aging face in this light. A grape becomes a raisin with loss of volume; in a similar fashion volume depletion of the aging face manifests as redundant skin. The effect of a facelift can be viewed as transforming the raisin into a pea by removing the redundant "shell" without addressing the volume loss. Therefore, returning the raisin to a grape, or the aged face to a youthful face, requires restoring the volume that is at least in part responsible for these changes.
When we look back at the results of our past efforts to rejuvenate the face, we can see that excisional-based surgery has not truly provided all the answers to facial rejuvenation. The hollowed out eyes that result from removing fat and skin during a blepharoplasty surely are not the ideal of a youthful countenance. At times, a perfectly performed facelift may produce an unnatural surgical result and not a rejuvenated appearance. Clearly, there is more to restoring a natural more youthful facial appearance than what just lifting can provide.
Is volume expansion then the only method acceptable to rejuvenate the face? Should the experienced plastic surgeon who is adept at browlifting, facelifting, etc., throw out all that he or she has learned and start over with just filling the face with fat? Certainly, many advocates of full-face fat transfer have shown remarkable clinical results that testify to the potency of fat grafting alone with longevity that has rivaled traditional lifting procedures.
Although the aging face can be readily addressed in many circumstances with full-face fat transfer, the quantity of fat needed to achieve the intended result can be considerable, exceeding 100 cc during a procedure. Because proper fat infiltration requires multiple tiny passes with the infiltrating cannula to attain a viable, long-lasting result, an individual who has received a sizable amount of fat during a session can suffer from a marked recovery period, characterized by gross, lingering edema and ecchymosis. At times, traditional lifting procedures combined with fat grafting can reduce the amount of fat needed to arrive at the desired result and thereby limit morbidity without aesthetic compromise. Deciding whether to perform facial fat grafting alone, a lifting procedure, or a combination of the two will be thoroughly discussed in the second chapter. Implementation of how to perform each type of procedure alone or in combination will then be discussed in the third chapter. This book will not explain how to perform a facelift, blepharoplasty, etc., as sufficient numbers of books have already been written about these topics. The book assumes a prerequisite knowledge on how to perform non-fat grafting rejuvenative procedures. The emphasis instead is on fat grafting and how to integrate fat grafting into an existing plastic surgical practice. If the surgeon is unfamiliar with other types of rejuvenative procedures and elects only to perform fat grafting, this book will also be very useful toward that end.
We propose an integrated philosophy that permits the combination of lifting procedures with volume enhancement. Paradigms are merely models for viewing and understanding the world around us. No one paradigm can explain everything. Rather than subscribe to a single paradigm and constrain all our view through the narrow confines of that model, we would like the reader to be more embracive of all techniques that can be beneficial for a particular patient and select the combination of techniques that will work based on that patient's particular anatomy and aesthetic desires. Like a painter with many sized brushes and a full color palette, the surgeon can be more creative and open when approaching the aging face. At times, full-face fat grafting will work beautifully. Other times, lifting procedures alone will probably suffice. Most often, a judicious combination of both treatment modalities will be superior. As stated, the second chapter of this book will guide the reader in a detailed preoperative evaluation of the face to determine which procedures would be best suited for a prospective patient. This chapter is intended only to set forth our paradigm of the aging face, which integrates prior work filtered through a new perspective.
Where should our search begin when looking for the quintessence of ideal, youthful beauty? Should we look at the aging face and think of how to rid it of unsightly wrinkles, sagging tissues, etc.? The answer is an unequivocal no. We should begin by determining what constitutes a youthful countenance so that we can strive toward that ideal. Too often, surgical plans begin and end with how to eliminate the face of "aging" without any clear understanding of youth. That is why a facelift can straighten a jawline but still leave the individual feeling as if he or she appears old. A pulled and stretched face does not necessarily resemble a youthful face, or more precisely, what that individual looked like in the past.
What makes a face appear young, vibrant, and ultimately alluring? When we look at a young face, how do we know that it is in fact a youthful face? Is it just the absence of lines and wrinkles? Is it just volume? Looking at nature, i.e., observing youthful faces that are all around us, will provide part of the answer. Without a frame of reference though, it may be hard to render accurate judgment as to what constitutes a youthful face, i.e., youth compared against the aging face will help to delineate the differences that make a youthful face uniquely distinct. (For example, reviewing photographs of a patient when they were younger can help establish the particular goals and plan for rejuvenating that patient.) The remaining chapter will be divided into three sections that describe the fundamental qualities of youth and the evolution of those qualities over time: Volume and Shape, Highlights and Shadows, and Framing the Eye. Viewing the youthful (and aged) face with these proposed principles will not only generate an insightful aesthetic philosophy but in so doing serve as the underpinning for an effective and systematic surgical plan.
Volume and Shape
Women tend to scrutinize their faces with the absolute, unforgiving lens of a mirror at 8 or 10x magnification. Fine lines, uneven texture and color become the focus of attention at this level of magnification and at such close inspection; and oftentimes women present to the plastic surgeon with alarm regarding these fine lines and other minor skin imperfections. Understanding how women view themselves can provide the surgeon the proper eye with which to view and understand their perception of aging. Nevertheless, the fundamental change from youth to age lies not in the minor cutaneous flaws that develop over time but in the overall change in volume and shape. How does a casual viewer almost instantaneously perceive that another individual several feet away is 15, 25, 35, 45, or 55 years of age before even a detailed facial analysis has been rendered? The answer lies fundamentally in the perception of that individual's facial volume and shape. How does someone almost immediately know that an individual is 35 years old and not 15 years old? Wrinkles and lines have most likely not developed at this point, unless severe and repeated photodamage has ravaged the skin at an early age. Considering that the sun and other abusive behaviors are not in effect and eliminating any mannerisms or styles of dress that would suggest a person's age, an onlooker can most oftentimes still discern the age gap that would define someone as 35 and not 15. Again, the answer lies in the change over time in volume and shape. From 15 to 35 years of age, most individuals experience principally a change only in volume due to loss of overall soft tissue, known colloquially, as "baby fat". Oftentimes, women actually like this change from their twenties into their thirties when they begin to exhibit a leaner, more sculpted appearance. Suggestion that they need facial fat enhancement can be anathema at this point. However, in some very athletically inclined individuals the volume loss is accelerated and may impart an unhealthy, overly gaunt appearance that may connote the opposite of health, i.e., infirmness and aging. In these individuals who seek rejuvenation, any lifting procedure would most likely be premature, unnecessary, and futile in achieving any aesthetic improvement. In this instance, volume restoration is the primary tool for facial rejuvenation.
From the period of 35 to 45 years of age and beyond, gravitational forces and volume contraction are both at work, depending on the individual. Some experience marked signs of facial tissue descent; whereas others exhibit almost exclusively radial contraction of the face. The combination of both forces contributes ultimately to the change in facial shape over time from a youthful heart shape (or triangular shape) to an elongated rectangle (or square shape). The objective of surgery is to restore both the volume and the shape to the face to arrive at the ideal heart shape.
Facial fat and soft-tissue loss in the midface/cheek region partly contribute to the loss of the heart shape of the face. Further, the volume loss around the mouth, the chin, and prejowl sulcus combined with the descent of the jowls laterally create a loss of the bottom point of the heart and produces the appearance of a rectangular base. The rectangular appearance of the lower face can be masculinizing. The goal of rejuvenation is defined simply as trying to move that individual's face from a rectangle back in time to a heart and in so doing move attention away from the lower face back to the eyes (see the following section of "Framing the Eye" for more details). Evaluation of the face (described in the second chapter of this book) will help define the precise anatomic attributes that can be improved with selective procedures. In an effort to strive toward the ideal, heart-shaped face, brow position can play a critical role. A browlift, irrespective of technique, can actually elongate the face and thereby accentuate the rectangular configuration that is both masculinizing and connotes aging. If the brow is truly ptotic and is situated below the orbital rim, then browlifting can help restore the youthful vitality and femininity to the eye. However, in most patients volume enhancement of the brow may better restore the fullness typically seen in the youthful brow. Photographs of the patient at a younger age are crucial to this evaluation. Although this chapter really concerns ideal aesthetics, technique has been introduced only in so much as it relates to an understanding of currently proposed aesthetics. The aesthetic objective for facial rejuvenation should be to return the face toward the ideal heart shape, and brow position can be a major determinant in striving to achieve or, conversely, to undermine that standard.
Highlights and Shadows
The issue of "highlights and shadows" is intimately related to the previous section discussing "volume and shape". As the volume of the face contracts due to soft-tissue loss and the shape of the face elongates due to gravitational descent, the distinguishing highlights of youth give way to the characteristic shadows of senescence. The characteristic highlights of the youthful face are lost as the face deflates. Shadows arise as the tissues fall and are tethered by various retaining ligaments and concavities emerge from volume loss. Volume restoration combined with or without lifting procedures can reduce the unsightly shadows and recreate desirable highlights.
The principal highlights that underscore a youthful countenance are found at the lateral brow, the cheek, the upper lip, and the chin. Women often tease their eyebrow hairs, which appears attractive not only as a result of the crafted arched shape but also because the highlight along the lateral brow is rendered more exposed. With age, the cheek mound that frames the eye falls downward and involutes resulting in a conspicuous double contour that is exacerbated by the presence of the malar septum. The double contour arises from loss of malar volume and descent of malar tissue that presents superiorly to inferiorly as exposed orbital fat (bulge), the bony orbital rim (hollow), the descended malar fat (bulge), and the shadowed malar septum (hollow). The separation of the lower eyelid from the cheek with the appearance of the double contour is a notable stigma of aging, and every effort should be made to reunite these two areas into a confluent, single complex. The double contour should be viewed as a more important area to correct than a deepened nasolabial fold that can be present even in youth. The targeted fashion for addressing all of the highlights and shadows of the face will be presented in the second and third chapters of this book. Restoration of the lower-eyelid and cheek complex as a single unit will provide the requisite frame for the eye.
Although a convex and rounded face is associated with a youthful mien, some gender differences should be underscored. In particular a full and round anterior cheek is a feminine characteristic. For men who are interested in facial fat grafting, care should be taken not to overfill the anterior cheek that may render the face less masculine. In contrast, the strength of the lateral cheek and lateral jawline can be relatively more augmented in the male patient if he so desires in order to achieve a more ideal masculine shape. Studying patterns of what we prize in the ideal male face reveals these aforementioned attributes.
Framing the Eye
The eye should be the most captivating feature of the face, and the goal of facial rejuvenation is to bring back the beauty of the eye and attention to it. As discussed, the descended and deflated brow that collapses over the eye renders it looking tired and haggard. The lower eyelid is exposed and attention is drawn to the unsightly contour deformities of the lower-eyelid fat bulge and the skeletonized and descended cheek. Without a proper frame, the attractiveness of the eye is markedly diminished. Think of a receding hairline: an onlooker's eye is drawn immediately to it. Conversely, a natural, full hairline that serves as a frame for the face goes unnoticed and the onlooker's gaze is drawn back to the central face.
Should our goal then be to restore a full and sensuous upper and lower frame for every eye? Yes and no. The answer lies in a studious evaluation of youthful and beautiful eyes. There exist two principal variants of an attractive, youthful frame for the eye: a full lower-eyelid/cheek complex and a full upper-eyelid/brow complex (see figure 11) or, a full lower-eyelid/cheek complex and a sculpted upper-eyelid/brow complex. The first of these variants is encountered more commonly in a youthful face. How about a full upper frame and a hollow lower frame? This pattern is rarely observed but can occur when a very prominent bony superior orbital rim exists with relative malar hypoplasia and lower-eyelid hollowing. This variant is unattractive and can be improved with fat transfer to the hollow lower eyelid and cheek to establish improved balance and harmony. A full lower frame should always be a primary goal in facial rejuvenation.
Some surgeons rely on cheek implants to achieve an improved malar contour. However, use of an alloplastic malar implant alone in the aging face can actually worsen infraorbital hollowing and accentuate the absence of a proper lower frame for the eye. Why is this the case? Simply put, the implant cannot reside superior to the infraorbital nerve; and therefore, the hollow inferior orbital rim is only accentuated by the presence of a greater prominence immediately inferior to it. Nevertheless, use of an alloplastic implant can be very effective in combination with fat grafting for those individuals who lack sufficient body fat for fat grafting, e.g., athletes (as discussed more thoroughly in Chapters 2 and 3).
To better understand the concept of framing the eye, an example of an unframed youthful eye, an exception that proves the rule, is the so-called negative-vector eye. As described in previous literature, a negative-vector eye is one in which the globe rests anterior to the orbital rim giving the illusion of an unframed eye. Traditional blepharoplasty can exacerbate the appearance of a negative-vector eye by continuing to hollow the frame and thereby exposing the relative anterior position of the globe. Fat transfer can soften the appearance of a negative-vector eye but only as much as additional fat placement can match the anterior projection of the eye position. The negative-vector eye, whether found in the younger or older patient, is unattractive simply because of the relative lack of a frame for the eye.
Concluding Remarks
Beauty lies in the eye of the beholder, or so the saying goes. This chapter tries to define a new aesthetic that closely parallels natural patterns of beauty. Hopefully, in so doing, we have challenged the reader to re-evaluate his or her concept of what beauty is and whether surgical options of the past have truly been sufficient to arrive at that aesthetic ideal. However, after finishing this chapter, the reader may choose to reject part or all of the proposed philosophy, and that's just fine. Every surgeon and every patient will have a somewhat different judgment and opinion as to what constitutes beauty and what should be done to achieve the optimal result. Fundamentally, the most important harmonious union of opinion must lie between the surgeon and the prospective patient.
